tbuckley/cabot-search huggingface dataset:
Levine Cancer Institute Financial Toxicity Control Program: Expanding the program to reduce fiscal vulnerability of patients.
Authors: Megan Wayman, Donna Feild, Jennifer Goodnight, Jeffrey Wise, Ashley Ford, Derek Raghavan
Journal: Journal of Clinical Oncology (2022)

43 Background: It is well known that financial toxicity is becoming one of the most substantial problems encountered by patients receiving cancer care, and active solutions are required to address this (JCO Oncol. Pract., 2021, 17: e 1433-39). We have established a Financial Toxicity Tumor Board to address specific issues that cause out-of-pocket costs for patients and have saved more than $55 million per year in such costs to patients. A major contributor to patient-centric costs is denials from health insurance companies. We have developed an innovative, pharmacy technician program to assess and understand such denials and to avoid them proactively. Methods: Pharmacy technicians were inserted into an additional site’s treatment team to ensure appropriate prior authorizations were in place prior to patient infusion. Sequential and unselected data were collected over by the prior authorization technician. Medication denial reports generated by the financial clearance team were analyzed to identify issues that might be improved by changes in standard operating procedures in order to avoid recurrent concerns and these solutions were implemented. Results: The approach adopted by the LCI Financial Toxicity Tumor Board, with the use of additional pharmacy technicians to manage and preplan documentation, has resulted in a reduction of denials over a one-year period of from 16-18/month to 3-4/month with a concomitant additional saving to patients of $5,720,753. The expansion to an additional site over the evaluation period has preliminarily resulted in a 48% decrease in financial toxicity for patients as compared to the previous year. Conclusions: A reality of clinical practice is an ever-present fiscal tension between payers, patients and providers, with payers adopting increasingly complex rules and regulations to avoid payment of charges. When this occurs, patients inevitably sustain increased out-of-pocket charges and anxiety, contributing to the pattern of financial toxicity. The approach of using technical support staff to prospectively avoid insurance denials can be scaled universally to ensure that health insurance payers, while adhering to their defined rules and regulations, are held accountable for their contractual obligations.
Pilot study looking at barriers individuals face in receiving fertility care after diagnosis with a gynecologic cancer.
Authors: Julia Schlossman, Michelle Vu, Kelly Thevenet-Morrison, MaryAnn Wilbur
Journal: Journal of Clinical Oncology (2022)

287 Background: Individuals who have received treatment for gynecologic malignancy often have reduced fertility options. However, there is a paucity of data on patient experience about this aspect of their treatment. The primary objective of this study was to quantify individual patient wishes about fertility preservation and perceived barriers they may have faced in pursuing fertility preservation, if desired. Methods: An online survey of 21 questions was distributed to 228 patients ages 18-40 at the time of diagnosis with ovarian cancer, endometrial cancer, or cervical cancer at a single, large academic hospital. The survey questions prompted individuals to reflect on the time when they found out they had cancer to evaluate how their diagnosis changed their fertility goals, whether respondents felt they had received adequate counseling on potential harm to their fertility due to treatment, and whether they felt they were supported if they had plans to become pregnant in the future. Results: 53 patients completed the survey. Though 37 of the 53 patients (69.8%) knew cancer treatment impacted their fertility, 27 out of 53 (50.9%) respondents, did not feel they received adequate counseling at the time of diagnosis. The most frequent types of counseling patients received was verbal information from their oncologist (60.4% of patients) and researching independently (56.5% of patients). 18.9% of patients did not recall receiving any counseling. Looking at the types of fertility preservation patients underwent, 11 out of 53 (20.8%) had fertility sparing surgery and 6 (11.3%) tried various methods consisting of either oocyte preservation, ovarian tissue cryopreservation, ovarian transposition, or embryo cryopreservation. 35 patients (66.0%) did not undergo any fertility preservation. Patients who had children at the time of diagnosis were 75% less likely to undergo fertility preservation than patients who did not already have children at the time of diagnosis (Odds Ratio = 0.25; 95% CI: 0.059, 0.88). Patients who did not choose to undergo fertility preservation were prompted to evaluate various reasons preventing them from accessing fertility care. The most common barriers included not wanting to delay treatment (50% of respondents), not wanting to have children (21% of respondents), feeling too emotionally burdened by their diagnosis (19% of respondents), and lack of adequate counseling from their provider (15%). Conclusions: Though most patients received some counseling about the impact of treatment on their fertility, the majority of patients did not feel this counseling was adequate. More work needs to be done to understand how best to support patients in their fertility preservation wishes, if applicable, while planning treatment for gynecologic malignancies.
Physician-level variation in axillary surgery in older adults with T1N0 hormone receptor–positive breast cancer.
Authors: Christina Ahn Minami, Ginger Jin, Rachel A. Freedman, Mara A. Schonberg, Tari A. King, Elizabeth A. Mittendorf
Journal: Journal of Clinical Oncology (2022)

284 Background: Randomized controlled trial data support safe omission of axillary surgery in patients &gt;70 years old with T1N0 hormone receptor-positive (HR+) breast cancer, but utilization of axillary surgery in the U.S. remains &gt; 80%. We sought to assess the proportion of variance in axillary surgery receipt that is attributable to surgeon-level differences vs. patient level differences, and assess the patient- and surgeon-level factors that affect axillary surgery receipt in this population. Methods: Women &gt;70 years old with T1N0 HR+/HER2-negative breast cancer diagnosed from 2013-2015 in SEER-Medicare were linked to surgeon-level data from the American Medical Association Masterfile. Patients of low-volume surgeons (surgeons treating &lt; 5 patients in this population over the study period) were excluded. To assess patient-and surgeon-level factors associated with axillary surgery receipt, we estimated hierarchical logistic regression models regressing receipt of axillary surgery on surgeon-specific random intercepts (null model). We then re-estimated this model including patient factors (age, Charlson Comorbidity Index (CCI), and a validated claims-based frailty index). Our final model included other surgeon-, patient-, and disease-level factors. The intracluster correlation (ICC) was used to estimate the proportion of total variance in the outcome attributable to the surgeon level. Results: Of 4,410 women included, 58.3% were &gt;75 years old, 20.7% were frail, and 13.9% had a CCI&gt;2; 86.1% of women underwent axillary surgery. Of 432 surgeons represented, 52.6% were female and 9.5% identified as surgical oncologists. In the null model, 10.5% of the variance in the axillary evaluation was attributable to the surgeon-level, with 89.5% attributable to patient-level differences (Table). Adjusting for key patient-level variables (age, CCI, and frailty status) reduced unexplained patient-level variance, resulting in a greater proportion of total unexplained variance attributable to the surgeon level (13%). In our final model, physician subspecialty and years in practice were non-significant, but patients of female surgeons were less likely to undergo axillary surgery (OR 0.69, 95% CI [0.51-0.95]). Conclusions: In older women with T1N0 HR+ disease, patient-level differences reassuringly account for most of the variation in receipt of axillary surgery. Drivers of residual patient-level variation may include unmeasured factors such as differences in surgeon-patient communication and patient preferences.[Table: see text]
Integration of patient-reported outcomes into survivorship care.
Authors: Katherine Ramsey Gilmore, Patricia Hansberry Chapman, Johnny Rollins, Soo Lee-Kim, Justine Robinson, Ellen Mullen, Haleigh Mistry, Prachee Singh, Robin Coyne, Ana Nelson, William Osai, Karen Stolar, Susan Knippel, Danielle M. Fournier, Tamera Plair, Angela Peek, Maria Alma Rodriguez
Journal: Journal of Clinical Oncology (2022)

271 Background: Patient reported outcomes (PRO) can be valuable clinical tools to embed the voice of patients into the clinical experience. The use of PROs in the context of cancer survivorship is relatively under-explored. Methods: Disease-specific modules of the MD Anderson Symptom Inventory (MDASI) PRO were integrated into the electronic health record (EHR), and distributed 3-7 days prior to survivorship clinic visits through the patients’ EHR portal. Patients with virtual visits were called 24 hours prior, instructed how to video link, and how to complete the MDASI PRO. For patients who completed the PRO electronically, results were reviewed during clinic visit. High symptom alerts (&gt; = 7) for four key symptoms were established and triggered an automatic message to care teams for review. Results: From Sept 1, 2020 – August 31, 2021, 2,196 PRO surveys were sent to patients with 1,268 submitting results (57.74%) (see Table). Within specific clinics, the submission rates varied greatly between in-person and virtual appointments (33% vs. 83%). Submission rates varied by clinics, with responses ranging from 28.57% - 73.59%. Clinics with higher overall rates had a higher proportion of virtual visits. Conclusions: Electronic distribution of PROs can be successfully integrated into long term survivorship clinic visits. Virtual visits had overall much higher PRO response rates, due to pre-visit workflows which encouraged the completion of PROs. We conclude that patient education and real time support is needed to facilitate patients’ completion of PRO surveys through the electronic portal.[Table: see text]
Guidelines and workflow for virtual simulation.
Authors: Dhwani Parikh, Marisa Kollmeier
Journal: Journal of Clinical Oncology (2022)

49 Background: An important component of radiation treatment planning is the CT simulation which involves several steps including patient positioning, imaging in the treatment position, and placement of an isocenter, a point through which the central rays of the radiation beams pass. As radiation therapy is an important component of palliative treatment for metastatic cancer, some patients require multiple courses which may be temporally proximate. This creates a burden for patients who may be challenged with regard to mobility, distance, and logistics coordinating travel to the department. We sought a clinical workflow that maintains the integrity of the simulation process but allows the potential use of previously obtained treatment planning imaging to create a new treatment plan (i.e. virtual CT simulation). We present our workflow and experience here. Methods: A multidisciplinary group developed a virtual simulation workflow and identified critical criteria to safely and reliably proceed with virtual simulation. These included: time from initial CT simulation (&lt; 14 days), adequacy of patient positioning and immobilization, as well as appropriate inclusion of the entire “virtual” planning treatment volume (PTV) and organs at risk (OARs) in the original scan. Specific virtual simulation care paths were created in treatment planning software (Aria®, Varian Medical Systems) for case tracking. A pilot was initiated to monitor the workflow for the first 10 patients and corrections to the workflow were made. Thereafter the program was randomly audited and the QA reporting system monitored for reported error events. Results: The virtual simulation workflow pilot was initiated in June 2020. Of the first 50 virtual simulation requests, 48 were approved (96%). Two cases were denied due to inadequate immobilization. There was only one event reported pertaining to set up uncertainty requiring clarification from physics. Conclusions: Given the success of the virtual simulation criteria and workflow we will continue this practice and will monitor the cases as well as RISQ events closely. Based on feedback we have received we will expand the window of time to request a virtual simulation from 14 days to 21 days after original simulation and will also allow for up to 3 virtual isocenters to be placed.
Trends in the improvement in survival among patients with diffuse large B-cell lymphoma (DLBCL).
Authors: Kira MacDougall, Silas Day, Ryan David Nipp, Spencer Hall, Yan D. Zhao, Taha Al-Juhaishi
Journal: Journal of Clinical Oncology (2022)

147 Background: Advances in treatment for patients with DLBCL have led to improved patient outcomes, but whether disparities exist with regards to improved survival outcomes remains understudied. We sought to describe changes in DLBCL survival rates over time and explore potential differential survival patterns by patients’ race and age. Methods: We utilized the Surveillance, Epidemiology, and End Results (SEER) database to identify patients diagnosed with DLBCL from 1980-2009 and determined 5-year survival rates for all patients, categorizing patients by year of diagnosis. We used descriptive statistics and logistic regression, adjusting for stage and year of diagnosis, to describe changes in 5-year survival rates over time by race/ethnicity and age. Results: We identified 43,564 patients with DLBCL eligible for this study (median age 67 years [ages: 18-64 = 44.2%, 65-79 = 37.1%, 80+ = 18.7%], 53% male, 40% stage III/IV). Most were White race (81.4%), followed by race/ethnic groups of Asian/Pacific Islander (API) (6.3%), Black (6.3%), Hispanic (5.4%), and American Indian/Alaska Native (AIAN) (0.05%). Overall, the 5-year survival rate improved from 35.1% in 1980 to 52.4% in 2009 across all patients (odds ratio (OR) for 5-year survival with increasing year of diagnosis = 1.05, p &lt;.001). Patients in race/ethnic minority groups (API: OR = 0.86, p &lt;.0001; Black: OR = 0.57, p &lt;.0001; AIAN: OR = 0.51, p =.008) and older adults (ages 65-79: OR = 0.43, p &lt;.0001; ages 80+: OR = 0.13, p &lt;.0001) had worse 5-year survival rates adjusting for race, age, stage, and diagnosis year. We found consistent improvement in the odds of 5-year survival for year of diagnosis across all race and ethnicity groups (White: OR = 1.05, p &lt;.001; API: OR = 1.04, p &lt;.001; Black: OR = 1.06, p &lt;.001; Hispanic: OR = 1.05, p &lt;.005; AIAN: OR = 1.05, p &lt;.001) and age groups (ages 18-64: OR = 1.06, p &lt;.001; ages 65-79: OR = 1.04, p &lt;.001; ages 80+: OR = 1.04, p &lt;.001). Conclusions: In this analysis of SEER data, we found that patients with DLBCL experienced improvements in 5-year survival rates from 1980 to 2009, despite ongoing disparities demonstrating worse survival among patients in race/ethnic minority groups and older adults. Notably, we did not find differential improvement in the odds of 5-year survival within subgroups of race and age, underscoring the need for ongoing investigations to address disparities in cancer care delivery and outcomes.
The impact of geography on receipt of cancer treatment in Montana.
Authors: Jack Oliver Hensold, Heather Zimmerman, Janette K. Merrill, Sumitha Nagarajan, Diane Ng, Stephen S. Grubbs
Journal: Journal of Clinical Oncology (2022)

140 Background: The challenges of cancer patients in rural areas are well-documented. Most rural hospitals do not deliver on-site cancer care services and lack infrastructure, specialty physicians and oncology-trained support personnel (i.e., nurses, advanced practice providers, and pharmacists) to deliver infusion services. Because of this, cancer patients travel long distances to receive treatment. Travel distance is associated with an increased financial burden and worse outcomes with cancer, including later stage at diagnosis, less timely receipt of chemotherapy, and delay or declination of treatment. According to America’s Health Rankings, high geographic disparity within the state of Montana remains a significant challenge to overall health. Chronic understaffing of oncologists further exacerbates the geographic barrier to cancer care. Methods: To assess the impact of these combined access barriers to cancer treatment, we utilized 5 year cumulative data (2014-2018) from the Montana tumor registry database to assess the impact of geographic disparity on cancer care for patients in Montana. Results: Overall 19.2% of Montanans did not receive treatment following a cancer diagnosis. This is similar to the percentage of cancer patients in Delaware that did not receive treatment (19.1%). Although the population of Delaware is similar to Montana, it is 1.3% of the size. While this suggests that distance may not impact the receipt of treatment for cancer, further analysis of treatment data for Montana by county demonstrated broad discrepancies in the receipt of treatment: No treatment ranged from 12.5% to 30.3%. When mapped geographically the counties with the highest percentage of “no treatment” were distant from the 8 Commission on Cancer-approved cancer centers within the state. A similar county-by-county analysis demonstrated no apparent relationship of “no treatment” with either socioeconomic deprivation or lack of insurance. Distance from Commission on Cancer-approved centers also correlated with traveling out of state to receive care. Conclusions: This analysis provides insight into the impact of geographic barriers on cancer treatment in Montana and identifies remote sites that could benefit from robust outreach and care services to improve cancer care delivery.
Patient-reported hope, quality of life, symptom burden, coping, and financial toxicity in early-phase clinical trial participants.
Authors: Debra Lundquist, Andrea Pelletier, Sienna Durbin, Viola Bame, Victoria Turbini, Kaitlyn Lynch, Andrew Johnson, Hope Heldreth, Megan Healy, Casandra McIntyre, Dejan Juric, Rachel Jimenez, Betty R. Ferrell, Ryan David Nipp
Journal: Journal of Clinical Oncology (2022)

275 Background: Early phase clinical trials (EP-CTs) investigate novel treatment options in oncology, with recent advances in personalized therapy leading to improved outcomes and offering hope to patients with cancer. However, little research has sought to understand associations of patient-reported hope with quality of life (QOL), symptom burden, coping, and financial toxicity in EP-CT participants. Methods: We prospectively enrolled consecutive adults with cancer participating in EP-CTs at Massachusetts General Hospital from 04/2021-05/2022. Participants completed baseline surveys prior to treatment initiation that assessed hope (Herth Hope Index [HHI], higher scores indicate greater hope), QOL (Functional Assessment of Cancer Therapy-General), symptom burden (physical: Edmonton Symptom Assessment System [ESAS]; psychological: Patient Health Questionaire-4 [PHQ4]), coping (Brief COPE: self-blame, acceptance, denial, emotional support, active, behavioral disengagement), and financial toxicity (COST tool, higher scores indicate greater financial wellbeing). We used regression models to determine associations of hope scores with patient-reported QOL, symptom burden, coping, and financial toxicity. Results: Of 157 eligible patients, we enrolled 129 (enrollment rate 82.2%, median age = 62.5 years [range 33.0-83.0], 53.9% female, and 96.0% metastatic cancer). Most common cancer types were gastrointestinal (37.5%), breast (20.3%), lung (8.6%), and head and neck (7.8%). Patients had an average HHI score of 27.5 (range 15.3 – 36.0), with 30.5% reporting high levels of hope. We found associations of higher hope scores with better QOL (B = 0.24, p &lt; 0.001) and lower symptom burden (ESAS-physical: B = -0.14, p &lt; 0.001; PHQ4-depression: B = -2.07, p &lt; 0.001; PHQ4-anxiety: B = -0.93, p = 0.001). We also found that hope scores were associated with patients’ coping (self-blame [B = -1.44, p &lt; 0.001]; acceptance [B = 1.40, p &lt; 0.001], denial [B = -1.12, p = 0.004], emotional support [B = 0.99, p &lt; 0.001], active [B = 1.02. p = 0.001], behavioral disengagement [B = -2.52, p &lt; 0.001]). Lastly, we found that higher hope scores were associated with greater financial wellbeing (B = 0.11, p = 0.026). Conclusions: In this prospective cohort study, we demonstrated a substantial proportion of EP-CT participants had high baseline hope and identified associations of hope scores with other important patient-reported outcomes. Specifically, we found novel associations of higher hope scores with better QOL, lower symptom burden, more adaptive coping mechanisms, and greater financial wellbeing, underscoring the importance of targeting these patient-reported outcomes when seeking to enhance the care experience of EP-CT participants.
Harnessing academic-community partnerships to improve colorectal cancer screening rates in medically underserved communities.
Authors: Noelle K. LoConte, Allison Antoine, A. Michelle Corbett, Carrie Stehman, David Frazer, Abhishek Ticku, Aronica Williams, Elissa Sprecher, Allison Kos
Journal: Journal of Clinical Oncology (2022)

166 Background: Colorectal cancer continues to be very common, and a widening racial disparity has been demonstrated. Wisconsin’s Comprehensive Cancer Control Program which is a program of the University of Wisconsin Carbone Cancer Center partnered with nine Federally Qualified Health Centers (FQHCs) on this five-year program to increase colorectal cancer (CRC) screening. Methods: This project was funded by the CDC and was a partner of a state’s comprehensive cancer control program and a variety of community health centers. Activities included clinical and environmental assessment and baseline data review of CRC screening, identification of a CRC screening team at each clinic, selection and implementation and evaluation of a panel of evidence-based interventions (EBI) per the The Community Guide to Preventive Services. Ongoing implementation data tracking and monitoring strategies were used to create opportunities for data-informed decisions at each clinic. Results: FIT kits were the preferred CRC screening modality. The preferred EBI were patient reminder systems, provider reminders, reducing structural barriers, professional education, EMR improvements and small media. Screening rates for CRC increased by 17% over the course of the project with a peak weighted average of screening at 51.8% for eligible average risk adults, which was up from a baseline of 34.8%. Over 9,000 take-home stool kits were distributed, and a 60.7% completion rate was achieved. The positivity rate for the FIT kits across all centers was 7.6%. A subset of the patients with a positive FIT (n = 97) were reviewed and 53.7% (n = 51) did not have a documented colonoscopy in their electronic medical record. Conclusions: This project of an academic-community partnership was successful in increasing CRC screening in medically underserved communities in Wisconsin. The positivity rate in this high needs population was higher than expected based on prior publications. Further efforts should focus on decreasing the gap between positive FIT testing and completion colonoscopy.[Table: see text]